What is a trauma center? Emergency rooms and departments are able to treat ill and
injured people, while trauma centers are able to handle the most severe, life threatening
situations. When an injured person is brought into a trauma center with a complex injury, a
sophisticated, highly trained interdisciplinary team of health care professionals provides the
services needed to save that person's life and prevent further disability or physical deterioration.

Physician specialists: an integral part of the trauma team. Trauma care requires a
highly trained medical staff, functioning as a multidisciplinary team. Patients with traumatic
injuries often require a level of care that involves the services of physician specialists, including
neurologists, orthopedic surgeons, general surgeons, cardiologists, plastic surgeons, and
anesthesiologists, to ensure appropriate screening, stabilizing, and treatment of trauma patients.

The problem: a shortage of physician specialists available for emergency call. For
many years, many trauma centers across the nation have been facing a crisis securing physician
specialists for emergency call. The on-call specialist shortage is particularly acute for The
Queen's Medical Center since it is the lead and only trauma facility in the State of Hawaii. For
complex care, there is nowhere else nearby to obtain treatment.

Impact of the shortage of physician specialists. With trauma injuries, seconds count;
the chances of survival significantly decrease and the side effects of injury significantly increase
if appropriate care is not given in the first hour immediately following the injury. A shortage of
physician specialists can jeopardize a trauma team's ability to provide care. It also increases the
risk of delay in patient treatment which in turn increases patients' risk of harm.

Typically, the cost of running an emergency department is far higher than the total
payments received from patients treated.1 According to the American Hospital Association, one-third
of the nation's hospitals already operate in the red.2 A significant percentage of hospitals
are incurring high additional costs from having to pay physician specialists to provide emergency
call coverage. Between 2000 and 2004, thirty trauma centers closed as hospitals faced volume
increases, higher costs, liability concerns, and low or no payment for trauma services. Some of
the cities that have seen trauma centers close include: Los Angeles, California; Tucson, Arizona;
Birmingham, Alabama; El Paso, Sherman, and Texarkana, Texas; and Tulsa, Oklahoma.3

A weakened trauma center decreases a state's state of readiness to respond not only to a
normal flow of critically injured patients but to unforeseen disasters and emergencies as well.
The tragic events of September 11 and Hurricane Katrina illustrate that trauma readiness and
availability is every bit as much an issue of public safety as police and fire services.

Causes of the on-call physician specialist shortage. The reasons why fewer physician
specialists are taking emergency call tend to fall into four categories:

Uncompensated care. Across the nation, the costs of practicing medicine and
delivering trauma care have steadily increased, while reimbursements to physicians --
from health plans, managed care, Medicare, Medicaid, and safety net programs for
the uninsured -- have dramatically decreased. A Hawaii orthopedist notes, for
example, that over the last decade reimbursement for knee surgeries has dropped
from $4,000 to $1,400. Orthopedic surgeons are now paid less for a total hip
replacement than they were in 1976.

According to the American College of Emergency Physicians, about half of all
emergency services provided in the country are uncompensated and about forty-two
per cent are significantly underpaid or paid only after considerable delays. While
hospitals and physicians have absorbed uncompensated costs in the past by shifting
them to patients who could pay, it has become increasingly difficult to recover those
costs with the flat fees provided by many health plans.

Lifestyle. Few would envy the life of an on-call physician specialist. They are often
called to emergency departments many times a day to deal with complex cases, taking
them away from their practices and families and limiting their ability to see their own
patients. Because of the shortage of specialists, those who do take call often share a
heavier call schedule. In hopes of achieving a better work-life balance, many
specialists have reduced or eliminated emergency call.

Supply and demand. There is a national shortage of specialists in many areas
critical for trauma coverage. The physician workforce is aging and physicians are
retiring, slowing down, relocating, or leaving the practice. An increasing number of
physician specialists no longer need to have staff privileges at hospital emergency
rooms because they work in outpatient surgical centers and specialty hospitals. Over
the past decade, the number of physician training slots also has declined.

During malpractice crises, concerns are expressed that liability costs will drive high-risk
specialist physicians from practice, creating access-to-care problems. Indeed,
liability pressures may be leading to greater consolidation of high-risk specialty care
services in a smaller number of providers. While the problem is multi-factorial, with
reimbursement and managed care arrangements contributing significantly, physician
specialists perceive liability to be the strongest driver.

Government responses to improve the availability of physicians for emergency call.
The states have employed many strategies to help trauma care and improve the availability of on-call
physician specialists, including:

Developing dedicated public sources of funding to reimburse physician specialists
for uncompensated trauma services. These funds were found to be effective and
essential for maintaining trauma centers and ensuring the on-call availability of
physician specialists. However, trauma fund moneys cover only a small fraction of
uncompensated trauma costs. Additional funding sources are direly needed. Current
revenue sources for dedicated trauma funds include: surcharges tacked onto fines for
convictions for traffic violations and substance abuse- and firearm-related offenses;
surcharges tacked onto fees for driver's licenses, motor vehicle registration renewals,
and the sale, lease, or transfer of motor vehicles; taxes on cigarette sales; tobacco
settlement funds; sales and development taxes; and budget appropriations.

Implementing tort reforms, such as caps on damage awards in malpractice lawsuits,
that place limitations on traditional legal rules and practices to decrease claim filings
and damage award amounts. Underlying this response is the presumption that too
many malpractice claims are filed and that damage awards tend to be excessive.
These reforms may have a positive effect on physician supply in some instances and
may reduce the number of lawsuits filed, the value of awards, and insurance costs.
However, evidence on how premiums were affected is mixed and findings are at best
inconclusive. In this regard, researchers who study the tort system have found only a
loose connection between changes in claim filings and outcomes and premium spikes.
Policy makers should be wary of exaggerated and misdirected statistics offered in
support of partisan positions.

Implementing patient-centered and safety-focused reforms that strive to reduce
the incidence of medical error. Underlying these reforms is the realization that
capping damages on the back end of litigation does not address all of the factors on
the front end that lead to litigation. These reforms also recognized that:

Tens of thousands of people die in hospitals each year as a result of preventable
medical error, yet a malpractice claim is filed by only one of every eight
negligently injured patients;

Most claims are resolved at great expense and too slowly to correct mistakes;

Most medical errors do not result from individual incompetence or recklessness,
but from faulty systems, processes, and conditions that lead people to make
mistakes or fail to prevent them; and

Ineffective communication with patients ­ not poor treatment or negligence ­ puts
physicians at most risk of malpractice lawsuits.

Patient-centered and safety-focus reforms ensure that "adverse events" and errors are
reported, tracked, and analyzed so that physicians and hospitals can identify system
weaknesses and learn from their mistakes before more consequential events occur.
These reforms encourage open, frank communications between patients and
physicians, apologies, and quick resolution of claims through mediation to avoid
bitter and protracted lawsuits. For example, a growing number of states are passing
laws that protect an apology from being used against the physician in court.

Improving state licensing boards to enable quick investigation and prosecution of
physicians who have demonstrated a pattern of negligence. State medical boards are
accountable for the quality of health care provided by physicians within their
jurisdictions and for assuring that physician licensees are competent to practice
medicine. They have been criticized for taking too long to investigate negligent
providers; for not dispensing stiff penalties for those found guilty of negligence; and
for not providing adequate public information about those physicians who have had
disciplinary action taken against them. These boards can only perform their mission
if they are properly organized, effectively empowered, and adequately funded.

Improving the ability of insurance commissions to review and evaluate rates and
malpractice trends. This includes developing systems to ensure the collection and
tracking of comprehensive data on medical malpractice claims, including, for
example, the number of claims filed, the losses associated with these claims, premium
amounts, and the number of open and closed claims.

Implementing stop gap strategies, such as premium subsidies and state-run
insurance programs to help physician specialists meet immediate insurance
premium obligations and find liability insurance in the short term. Typically thought
of as short-term or providing an option of last resort, these strategies may not solve
the systemic issues that exist in the medical liability insurance market.

Mandatory call: pros and cons. Neither federal nor state law affirmatively requires an
individual physician to serve on-call. Most hospitals mandate some level of on-call coverage as
a condition of staff membership. While hospital-mandated call is effective in many states, many
hospitals are reluctant to enforce call mandates for fear of losing or repelling physicians. A
mandated approach, whether imposed by a hospital, a state licensing board, or state law, may
backfire if other on-call issues, such as physician burnout, uncompensated care, and liability
insurance availability and affordability, are not addressed.

Conclusions. Having more than one cause, the shortage of on-call physician specialists
at trauma centers clearly requires more than one solution. Pursuant to the Resolution that
requested this study, the Department of Health will be submitting a separate study with Hawaii-specific
information on these issues. With this information, policy makers will be able to begin
the process of determining what short- and long-term solutions to apply in their efforts to
improve the on-call availability of physician specialists to The Queen's Medical Center, the only
trauma center in the State of Hawaii.